Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part A claims billed for total knee arthroplasty or total knee revision on dates of service from January 1, 2023 through June 30, 2025. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Joint replacement surgery, also known as arthroplasty, is a major advancement in orthopedic medicine. The most frequently replaced joints are the hips and knees. The knee, being the largest joint in the body, is comprised of the distal femur, proximal tibia, and patella. It is divided into three compartments: medial, lateral, and patellofemoral; each lined with cartilage and enclosed by synovial fluid, which facilitates smooth movement.

Arthritis, including osteoarthritis, rheumatoid arthritis, and traumatic arthritis, is the leading reason for a total knee replacement. These conditions cause significant pain and limit daily activities like walking, squatting, and climbing stairs. Other indications for surgery include persistent swelling, stiffness, inadequate relief from medications, failed conservative treatment, osteonecrosis, and malignancy. The primary goals of knee replacement are pain relief and improved function. Sometimes, a revision surgery is needed due to persistent pain or declining function from issues such as infection, bone loss, fracture, loosening, or wear of the prosthesis.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with Diagnosis Related Group (DRG) codes specific to lower extremity joint replacements or revisions and Internal Classifications of Diseases-10 (ICD-10) Procedure codes specific to total knee joint replacements or revisions billed with dates of service January 1, 2023 through June 30, 2025. Medical record review will be performed on supporting documentation to determine if the total knee arthroplasty service or total knee revision performed in a hospital inpatient setting was reasonable, necessary, and billed appropriately.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. Detailed operative/procedure report
2. Initial admission assessment or reassessment
3. History and Physical reports (include medical history and current list of medications)
4. Documentation of complaints, pain level and activities of daily living (ADL) limitations
5. Medical record documentation that describes and supports other treatment(s)/medication(s) were tried and failed or were considered and ruled out
6. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
7. Beneficiary’s medical records (which may include practitioner medical records, hospital records, physical/occupational therapy notes) that support the service(s) provided is/are reasonable and necessary
8. Discharge summary from Hospital
9. Documentation to support medical necessity for performance of a bilateral procedure
10. Documentation to support the medical necessity of service and DRG billed
11. Providers and/or suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available. Please include a signature log or signature attestation for any missing or illegible signature within the medical record.
12. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician.
13. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
14. Medical record documentation to support national and local requirements.
15. Any other supporting/pertinent documentation
16. If medical record documentation is submitted via esMD Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
17. Please Note: The supplier or provider is responsible for obtaining all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.

References

Social Security Act (SSA), Title XI

• §1135 Authority to Waive Requirements During National Emergencies

SSA, Title XVIII

• §1815(a) Payment to Providers of Services
• §1833(e) Payment of Benefits
• §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• §1877(g) Blanket Waivers of Section 1877(G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
• §1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• §1886 Payment to Hospitals for Inpatient Hospital Services
• §1893 Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• §411.15(k)(1) Particular services excluded from coverage
• §412.2 Basis of payment
• §424.5(a)(6) Basic Conditions

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency. CMS-1744-IFC. Effective March 1, 2020. Retrieved from CMS-1744-IFC

Internet-Only Manual (IOM), Publication (Pub.) 100-04, Medicare Claims Processing Manual (MCPM)

• Chapter (Ch.) 1 General Billing Requirements
• Ch. 12, §40 Surgeons and Global Surgery
• Ch. 23, §10.2 Inpatient Claim Diagnosis Reporting
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

IOM, Pub. 100-08, Medicare Program Integrity Manual (MPIM)

• Ch. 3, §3.2.3.3 Third-party Additional Documentation Request
• Ch. 3, §3.2.3.4 Additional Documentation Request Required and Optional Elements
• Ch. 3, §3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3, §3.3.2.1 Documents on which to Base a Determination
• Ch. 3, §3.3.2.4 Signature Requirements
• Ch. 3, §3.3.3 Reviewing Claims in the Absence of Policies and Guidelines
• Ch. 3, §3.4.1.3 Diagnosis Code Requirements
• Ch. 3, §3.6.2.1 Coverage Determinations
• Ch. 3, §3.6.2.2 Reasonable and Necessary Criteria
• Ch. 3, §3.6.2.3 Limitation of Liability Determinations
• Ch. 3, §3.6.2.4 Coding Determinations
• Ch. 3, §3.6.2.5 Denial Types
• Ch. 6, §6.5.4 Review of Procedures Affecting the DRG
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

Local Coverage Determination (LCD)

• L33456 Total Joint Arthroplasty
• L33618 Major Joint Replacement (Hip and Knee)
• L36007 Lower Extremity Major Joint Replacement
• L36039 Total Joint Arthroplasty
• L36575 Total Knee Arthroplasty
• L36577 Total Knee Arthroplasty
• L39911 Total Joint Arthroplasty. Effective October 13, 2024

Local Coverage Article (LCA)

• A56777 Billing and Coding: Total Joint Arthroplasty
• A56796 Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)
• A57428 Billing and Coding: Total Joint Arthroplasty
• A57685 Billing and Coding: Total Hip Arthroplasty
• A57686 Billing and Coding: Total Knee Arthroplasty
• A57765 Billing and Coding: Major Joint Replacement (Hip and Knee)
• A59811 Billing and Coding: Total Joint Arthroplasty. Effective October 13, 2024

Last Updated Sep 24, 2025